A fourth - and perhaps more powerful - tool against suicide is the comfort level of caregivers and family members in talking openly about it, said Dr. W. Vaughn McCall, Chairman of the Department of Psychiatry and Health Behavior at the Medical College of Georgia at Georgia Regents University.

Suicide is among the top 10 causes of death in the United States for every group age 10 and older, according to the Centers for Disease Control and Prevention.

"We need to get this on the table and keep this on the table," McCall said. McCall, Department Vice Chairman Dr. Peter B. Rosenquist, and MCG psychiatrist, Dr. Adrianna Foster, led the workshop, "New Developments in the Identification of Suicide Risk," at the American Psychiatric Association Annual Meeting May 3-7 in New York.

"We have made progress increasing young people's comfort and maybe even older people's comfort at talking about issues such as sex, alcoholism, and drug abuse but we have not crossed that hurdle with suicide," McCall said. In fact, one of his many goals is for primary care givers to incorporate these conversations into their regular patient checkups.

"You should be able to talk about suicide without blame, shame, or accusation," McCall said.

Increased comfort can start in medical school where Foster is using a computer-simulated patient to help students broach the topic of suicide. Students progress to seeing standardized patients, essentially actors simulating a mood disorder or other mental-health problem.

Foster is still analyzing data, but preliminary information from the study, funded by the American Foundation for Suicide Prevention, suggests that this simple, digital teaching aid can enhance medical students' ability to recognize suicide risk.

Technology is also helping ensure that every patient seeking psychiatric care at Georgia Regents Health System receives a suicide assessment. Rosenquist worked with Dr. David Fallaw, an internist and Chief Medical Information Officer for Georgia Regents Medical Center, to automatically link the electronic medical record to an established suicide risk assessment.

"It's a forced choice," McCall said. "You cannot sign and complete the electronic medical record until you have also done the C-SSRS," he said. McCall is referencing the Columbia-Suicide Severity Rating Scale, developed by Columbia University Medical Center, that has proven successful at predicting suicide attempts in adolescents and adults. The C-SSRS also is activated whenever a red flag is raised in the provision of care, such as a trauma patient talking about escalated drinking and negative thinking.

The assessment starts with pointed questions about whether a patient has thought in the past week that he would rather die in his sleep than wake up and whether he has actively thought of killing himself. The answers are typically 'no,' and the survey is over. Otherwise, increasingly specific questions follow, including questions about methods.

"It's a hierarchy of planning that leads from no ideas to some ideas to a specific plan to collecting the implements to intention to carry it out," McCall said. C-SSRS also walks the caregiver through suggested levels of intervention as needed.

Insomnia is increasingly emerging as a clear risk factor for suicide although even mental health professionals are still absorbing the correlation. "The most secure message is that patients who have significant complaints about insomnia should be assumed to be at increased risk of suicide," said McCall, who studies the connection between depression, insomnia, and suicide. Researchers have established a connection at many levels, including, as McCall has shown, a general sense of hopelessness that can result from insomnia.

"This is a basic biological function and even this is beyond me," he said, reflecting the thoughts of patients who have been struggling weeks or more just to sleep. Additionally, a history of suicide attempts often correlates with low levels of serotonin, a neurotransmitter involved in sleep and depression. In fact, McCall is leading a National Institute of Mental Health-funded clinical trial to determine whether adding a sleeping pill to their therapeutic regimen reduces suicidal thoughts in depressed patients with insomnia.

Another possible link is early - but not surprising - evidence associating suicide attempts with problem-solving deficiencies, which links back to insomnia. "People who have not gotten enough sleep simply are unable to solve problems with the same degree of complexity as well as people who have gotten a good night's sleep," McCall said.

Insomnia rates are on the rise in this country with ever-present light and communication as key intruders on this very basic biological function, McCall said. Suicide rates also are on the rise as a major cause of death in the world, moving from 14th to 13th in global death rates from 1990 to 2010, according to the Global Burden of Diseases, Injuries and Risk Factors Study 2010 ranking causes of death in nearly 200 countries.

Meanwhile, other largely preventable deaths such as infections from unclean water and lack of vaccinations, have mostly taken a nose dive.

"'While we as a world population are successfully impacting infectious diseases and reducing their impact on world mortality, essentially nothing has been done about suicide so it correspondingly moves up," McCall said. "It will never get better if we can't even talk about it."

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